Obama signs landmark health reforms as opponents vow repeal

Republicans unveiled legislation and lawsuits to invalidate the measure the same day it was enacted.

By Doug Trapp — Posted March 29, 2010

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As supporters of health system reform claimed victory and trumpeted the enactment of the most significant health care expansion in more than four decades, those opposing the new law vowed to block implementation of its central requirement for individuals to have health insurance.

President Obama on March 23 signed the Patient Protection and Affordable Care Act at a White House ceremony. The law is expected to provide a combination of public and private coverage for more than 30 million uninsured Americans by 2019, leaving 23 million people, about 8% of the U.S. population, without coverage.

Obama said the legislative achievement, some form of which presidents have been attempting throughout the last century, was improbable and remarkable. He said the law establishes "the core principle that everybody should have some basic security when it comes to their health care."

Some of the enacted health insurance reforms take effect this year, but the heart of the legislation does not emerge until 2014. That year Medicaid eligibility increases nationwide to 133% of the federal poverty level, state health insurance exchanges begin operating, and requirements for many Americans to have health insurance or pay tax penalties start. Many businesses also will be required to help pay for their workers' coverage.

GOP lawmakers in Congress -- none of whom voted for the final bill -- vowed to battle its implementation. "Republicans will continue to stand on principle, hold President Obama accountable for his promises and fight to repeal this government takeover of health care so we can start over on common-sense reforms," House Minority Leader John Boehner (R, Ohio) said on March 23.

Many physician organizations lauded the bill's signing, but some qualified their support.

American Medical Association President J. James Rohack, MD, called it "a monumental moment in the health of our nation." But he said the AMA is concerned about the new Medicare Independent Payment Advisory Board that will direct ways to reduce the growth in Medicare spending starting in 2015, a process that could lead to doctor pay cuts. The act does not address the current physician pay problem nor offer a replacement for Medicare's sustainable growth rate formula.

Despite the unresolved pay issues, many physicians said the overall reforms were badly needed. In addition to the coverage expansions, the act boosts some Medicare primary care pay and supports more physician training.

Dozens of members of Doctors for America -- a liberal-leaning group founded by Massachusetts physicians last year -- held a March 22 rally on Capitol Hill. They shared stories about patients who suffered because they were uninsured or could not afford care. Leaders of the American Academy of Pediatrics, the American College of Physicians, the American Academy of Family Physicians and the American Medical Student Assn. said at the event that the law is a giant step forward.

Rep. Jim McDermott, MD (D, Wash.), said the work on this law is just beginning, noting that Medicare has been amended every year since it was adopted in 1965. He told the many young physicians at the rally that they will be the ones trying to make the health system more effective and efficient.

"The job's not done. ... You are going to be the energy to make that happen," Dr. McDermott said.

But the spokesman for a coalition of 14 conservative-leaning physician organizations that opposed the Democrats' health reform legislation warned that the act's coverage expansions will not be effective.

M. Todd Williamson, MD, of the Coalition of State Medical and National Specialty Societies, said giving 16 million more people Medicaid coverage, for example, does not make sense when some existing enrollees have difficulty getting care. "You may be handing them insurance, but you're not handing them access." Dr. Williamson is also past president of the Medical Assn. of Georgia.

Physicians for a National Health Program -- which supports a single-payer system -- said on March 22 that the act is a gift to the private health insurance industry and maintains the country's fragmented health care system. "This bill's passage reflects political considerations, not sound health policy," the group said.

The 15 congressional physicians all voted on the measure along party lines. (There is a 16th physician, Rep. Donna M. Christensen, MD, a Democrat representing the Virgin Islands, but she does not have a vote.)

Repeal effort under way

Even before Obama signed the bill into law, at least two states -- Virginia and Idaho -- had adopted laws aimed at preventing its residents from being subject to the bill's individual insurance mandate. Arizona voters in November will consider a constitutional amendment to do the same.

Federal statute generally preempts state laws. But Idaho Attorney General Lawrence Wasden announced on March 23 that his state was joining at least 12 others in filing a lawsuit challenging the constitutionality of the act's requirement for individuals either to have qualifying health insurance coverage or pay a tax penalty.

"We contend the federal government has overstepped its authority with this law and that it's our duty to challenge it," said Wasden, who is working with other attorneys general in Alabama, Colorado, Florida, Louisiana, Michigan, Nebraska, Pennsylvania, South Carolina, South Dakota, Texas, Utah and Washington. All but one of the attorneys general is a Republican. Also, Virginia is filing its own suit challenging the measure's constitutionality.

The joint lawsuit also targets the act's Medicaid expansion. Although the federal government would pay for 100% of the expansion's cost from 2014 to 2016, it reduces support in subsequent years to reach 90% after 2019, costing states millions.

Twelve GOP senators also introduced legislation on March 23 to repeal the health reform act.

Reconcilable differences

Meanwhile, Democrats were seeking their own changes to the Patient Protection Act. Immediately following the landmark reform vote, the House on March 21 approved a package of revisions that helped secure the votes for the underlying act.

The amendments bill would, for example, remove special deals negotiated by Senate Majority Leader Harry Reid (D, Nev.) to attract votes for the Patient Protection Act late last year. These included permanently covering 100% of the Medicaid expansion's cost in Nebraska and preventing cuts to private Medicare plans in Florida. If approved by the Senate, the revisions bill also would increase Medicaid primary care pay to Medicare levels in 2013 and 2014, reduce an excise tax on high-cost insurance plans, further increase funding for community health centers, raise fees on brand-name drug companies, and change the tax penalty structure for the individual insurance mandate.

The Senate on March 24 started considering the revisions bill under the budget reconciliation process, which allows approval by a simple majority of senators. Senate Republicans vowed to amend the bill before final Senate approval, which would send it back to the House. But House Democratic leaders said the amendments are popular enough to survive multiple House votes.

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Phasing in health reform

Some of the key provisions of the Patient Projection and Affordable Care Act will be implemented over the coming months and years, although revisions under consideration in the Senate could change parts of the timeline.


  • Offers tax credits to small businesses that offer health coverage.
  • Starts to close the Medicare drug benefit's coverage gap to eliminate it by 2020.
  • Authorizes the creation of a 15-member Medicare Independent Payment Advisory Board to extend Medicare's solvency, lower health care costs and improve health outcomes.
  • Extends the Medicare Physician Quality Reporting Initiative through 2014, establishing a physician appeals process and penalizing nonreporting doctors starting in 2015.
  • Authorizes the Food and Drug Administration to create a pathway for approval of biosimilar versions of biologic drugs.
  • Extends the Medicare work geographic practice cost index floor through 2010.
  • Provides funding for the practice expense geographic practice cost index floor for 2010 and 2011.

90 days after enactment (June 2010)

  • Creates a temporary high-risk pool for Americans who are uninsured due to a preexisting condition.

6 months after enactment (September 2010)

  • Prohibits health plans from canceling coverage for people who get sick and placing lifetime caps on benefits.
  • Tightens restrictions on annual coverage limits.
  • Extends health insurance eligibility for dependents to age 26.

By the end of 2010

  • Begins greater investments in primary care physician training and community health centers.
  • Prohibits physician-owned hospitals without a Medicare provider agreement from participating in the program.


  • Eliminates co-pays and deductibles for Medicare preventive care.
  • Requires individual and small group health plans to spend at least 80% of premiums on health care; increases the floor to 85% for large group plans.
  • Creates a long-term-care insurance program for adults with disabilities.
  • Provides a 10% Medicare pay bonus from 2011 to 2015 for certain primary care and major surgical procedures in health professional shortage areas.


  • Prohibits health plans from denying coverage to anyone with a preexisting condition.
  • Expands Medicaid eligibility nationwide to 133% of the federal poverty level.
  • Directs the Dept. of Health and Human Services to create health insurance exchanges in states that have none.
  • Establishes government subsidies for people earning between 133% and 400% of poverty to buy coverage through exchanges.
  • Requires individuals to have a minimum level of coverage or pay penalties.
  • Requires all but small employers whose workers enroll in exchange plans to help pay for the coverage.
  • Begins reducing federal funding to safety net hospitals for the care of low-income people.


  • Allows recommendations of the Medicare Independent Payment Advisory Board to start taking effect unless overridden by supermajorities in both houses of Congress.

Sources: House Energy and Commerce Committee, House Ways and Means Committee, House Education and Labor Committee (link); Senate Democratic Policy Committee (link)

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The long road to reform

Democrats spent more than a year attempting to enact national health system reform legislation.


March 5: President Obama invites health care stakeholders to a White House summit to launch the official health system reform effort.

April 8: Obama creates the White House Office of Health Reform.

June 17: Sen. Chris Dodd (D, Conn.), acting chair of the Senate HELP Committee, begins marking up a partial health reform bill.

June 19: Chairs of three House committees introduce a draft version of their national health reform bill.

July 31: Conservative Democrats force the House Energy and Commerce Committee to make major changes to a national health reform bill before the panel approves it.

August: Reform opponents disrupt town hall meetings held around the country, and polls begin to show a majority of Americans disapprove of the Democrats' plans, despite the popularity of many bill provisions.

Aug. 9: Former GOP vice presidential candidate Sarah Palin popularizes the term "death panels" to describe a House bill provision on Medicare end-of-life-care counseling.

Aug. 25: Sen. Edward Kennedy (D, Mass.), HELP chair and health reform champion, dies from a glioblastoma.

Sept. 9: During a congressional address on health care, Rep. Joe Wilson (R, S.C.) shouts "You lie!" challenging Obama on the issue of coverage for illegal immigrants.

Sept. 16: Senate Finance Committee Chair Max Baucus (D, Mont.) introduces a bill aimed at bipartisan compromise that picks up only one Republican vote on the panel.

Nov. 7: The House adopts the Affordable Health Care for America Act, 220-215.

Dec. 24: The Senate approves the Patient Protection and Affordable Care Act, 60-39, based on the Finance and HELP bills.


January: Democratic leaders begin negotiations to merge the House and Senate bills.

Jan. 19: Massachusetts voters elect Republican Scott Brown to the Senate, ending Democrats' 60-seat supermajority in the Senate and temporarily putting reform talks on hold.

Feb. 25: Obama holds a second White House health reform summit in an attempt to jump-start the effort.

March 21: The House adopts the Patient Protection and Affordable Care Act, 219-212. The House also passes a package of revisions designed to become law with a simple majority vote in the Senate.

March 23: Obama signs into law the Patient Protection and Affordable Care Act.

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